I.  DEMOGRAPHICS

Location of personal residence (zip code)

Question Title

* 1. Location of personal residence (zip code)

Location of primary practice site (zip code)

Question Title

* 2. Location of primary practice site (zip code)

Do you currently hold a PHDHP license?

Question Title

* 3. Do you currently hold a PHDHP license?

If answered YES to Question #3, list license number and date issued:

Question Title

* 4. If answered YES to Question #3, list license number and date issued:

Are you eligible for PHDHP licensure?

Question Title

* 5. Are you eligible for PHDHP licensure?

Do you currently hold a Local Anesthesia license?

Question Title

* 6. Do you currently hold a Local Anesthesia license?

If answered YES to Question #6, list license number and date issued:

Question Title

* 7. If answered YES to Question #6, list license number and date issued:

Are you currently a School Certified Dental Hygienist?

Question Title

* 8. Are you currently a School Certified Dental Hygienist?

Are you currently a Member of the ADHA?

Question Title

* 9. Are you currently a Member of the ADHA?

T